Impact of an ICU Liaison Nurse Service on major adverse events in patients recently discharged from ICU

doi:10.1016/j.resuscitation.2009.10.011

Resuscitation

Volume 81, Issue 2, February 2010, Pages 198-201

https://doi.org/10.1016/j.resuscitation.2009.10.011 Get rights and content

Abstract

Aim

To identify the effect of an ICU Liaison Nurse (LN) on major adverse events in patients recently discharged from the ICU.

Methods

Case–control study using a chart audit protocol to assess controls retrospectively and cases prospectively. Controls did not receive ICU-based follow-up care. Cases received at least three visits over 3 days from the ICU LN. The LN service operated 7 days/week 0800–1800. Data on a range of predictors and three major adverse events (unexpected death, surgical procedure needed, and transfer to a higher level of care) were collected using a purpose built audit form.

Results

A total of 388 patients (201 controls and 187 cases) were included in the study. Demographic and clinical characteristics were similar for both groups. A total of 165 major adverse events were identified in 129 patients. After controlling for all other potential predictors, patients who received the LN intervention were 1.82 times more likely to be transferred to a higher level of care (P = 0.028) and 2.11 times more likely to require a surgical procedure (P = 0.006). Surgical patients were 7.20 times as likely to require a surgical procedure (P < 0.001).

Conclusions

Our results support the claim that ICU LN has a role in preventing adverse events. However as the control data was retrospective and the study was conducted at one site, other unknown factors may have influenced the results.

Introduction

Patients who have recently been transferred from ICU to a general ward represent a vulnerable group who often have complex care needs¹ which places them ‘at risk’1, 2, 3 because general ward staff may not have the knowledge or skills to provide appropriate care.4, 5, 6, 7 Bledon et al.⁴ demonstrate that an increased rate of medication errors, lack of care coordination and poor communication between medical and nursing staff occur with more acute patients on the ward, and assert that health system reform must address these problems. Managing high acuity patients on the ward also adversely affects the quantity and quality of care available for less dependent patients.⁸

Recently in Australia the use of an ICU Liaison Nurse (LN) service has emerged to improve the transitional care of patients from the ICU to the ward9, 10; however little is known about its effect on patient outcomes. To that end, we report on a study that examined the effect of an ICU LN service on major adverse events occurring in patients in the first 3 days after transfer from ICU to the ward.

The major responsibilities of ICU LNs are to facilitate ICU patient discharge, follow up, assessment and support, to manage unstable patients in ward areas and to provide a critical care resource for ward staff. ICU LN services range from 5 to 7 days/week services, with hours ranging from 8 to 24.11, 12, 13 ICU LN services have been shown to decrease ICU discharge delay¹⁴ and improve ICU nurses’ perceptions of discharge planning,⁹ and have been well received by ward staff.¹⁵ Less is known about their effect on patient outcomes such as cardiac arrests and ICU readmissions, although one recent cohort study did not show that access to an ICU LN service predicted the occurrence of adverse events.¹⁶

Section snippets

Aims of the study

The aim of this study was to identify the effect of an ICU LN service on major adverse events in patients recently discharged from the ICU.

Two research questions were derived from this aim:

1.
What is the frequency of major adverse events in two groups of patients, those who receive and do not receive care from the ICU LN service, in the 72 h after discharge from ICU to a medical or surgical ward?
2.
What are the predictors of major adverse events in the 72 h after patients are discharged from ICU to a

Methods

A case–control study using a chart audit protocol was used to answer the research questions. Controls were reviewed retrospectively and cases prospectively. The study was conducted from January 2005 to January 2006.

Sample

This study was set in one regional hospital with 220 beds in Victoria, Australia. All patients discharged from ICU were included in the study if their ICU length of stay was 24 h or longer. Patients were included only once, on their first admission to the ICU, during the study period. Patients who were transferred to other hospitals or discharged directly home were excluded from the study.

Intervention

The LN intervention was provided 10 h per day (0800–1800), 7 days a week, similar to ICU LN service provision across Australia at the time of the study.10, 12, 13 Each LN was an experienced Registered Nurse with specialist critical care qualification. Additional training was provided to the LNs to standardise the intervention. LNs visited patients at least daily for the first 3 days after ICU discharge. During this visit, they assessed the patient clinically, reviewed their charts, discussed

Predictors and outcomes

We used the generally accepted definition of adverse event: “an unintended injury resulting from health care management, rather than the disease process”.¹⁷ Previous studies have also focused on antecedents of major adverse events18, 19, 20 generally defined as unexpected deaths, cardiac or respiratory arrest, severe respiratory distress and ICU readmission. We examined three major adverse events: unexpected death, transfer to a higher level of care (either high dependency or ICU readmission),

Data collection

A chart audit was used to collect the data. This audit occurred retrospectively for the controls and prospectively for cases. A slightly modified case record form developed in previous studies16, 21 was used by a Research Assistant (RA) to extract chart data. The RA was an experienced Registered Nurse who underwent training in the protocol and who was unaware of the aim of the study. The chart audit protocol involved careful reviewing of the patient's medical records including various flow

Data analysis

Descriptive statistics were used to identify the characteristics of the sample and the frequency of major adverse events. t-Tests and chi-square tests were used to identify differences between cases and controls in terms of demographic and clinical characteristics. The association between the LN intervention and the incidence of each of the major adverse events was first determined using a univariate logistic regression. Crude odds ratios along with 95% confidence interval and the associated P

Results

A total of 388 patients (201 controls and 187 cases) were included in the study. Demographic and clinical characteristics were similar for both groups (Table 1). Both groups’ average age was just under 70 years and included more males than females. Both groups had an average ICU length of stay of less than 4 days and an average hospital stay of 12 days. Just over 20% of both groups were discharged from ICU out of hours or during the weekend.

Table 2 identifies the frequency of adverse events and

Discussion

Just under 400 patients were included in this case–control study of major adverse events after ICU discharge. Cases and controls were similar in all demographic and clinical characteristics.

In this study, 165 major adverse events were experienced by 129 patients, i.e. just under 32% of patients experienced at least one major adverse event. This is higher than a previous Australian study of adverse events after ICU discharge with Chaboyer et al.¹⁶ reporting that 11% of patients experienced a

Conclusions

Our results support the role of the ICU LN in preventing adverse events after ICU discharge. However given control data was retrospective and the study was conducted at one site, a number of other unknown factors may have influenced the results. The number of adverse events reported in this study suggests that contextual and organisational factors should be explored further.

Conflict of interest

None.

Acknowledgements

This study was funded by the Victorian Department of Human Services and the Victorian Medical Insurance Authority. Neither sponsor had any involvement in the study design, data collection, analysis or interpretation, writing of the manuscript or decision to submit the manuscript for publication.

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Endacott R, Eliott S, Chaboyer W. The Intensive Care Unit Liaison Nurse role: activities and outcomes. An integrative...

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Intensive Care Unit Liaison Nurse roles are associated with improved clinical outcomes for patients and financial benefits for healthcare providers. However, there is little academic exploration of the ward nurses’ perspectives of the role and whether it can affect ward nurses’ confidence in identifying and managing the deteriorating patient. This study addresses this gap by examining both those perspectives.
A qualitative descriptive approach was used, utilising semi-structured interviews to garner the perspectives of ward nurses. Interviews were conducted with ward nurses who had been involved in a Medical Emergency Team/Code Blue call; sought technical or clinical support; or had been at the bedside during a post intensive care unit discharge review. Data were analysed using thematic analysis.
A private, not-for-profit, metropolitan acute care hospital.
The participants identified four areas that contributed to improved patient care: reduced Medical Emergency Team/Code calls; improved ward based critical care knowledge through education; improved ward nurses’ confidence in dealing with the deteriorating patient and provision of technical support.
The Intensive Care Unit Liaison Nurse role not only contributes to improved clinical patient outcomes; it also influences confidence levels of the ward nurses in managing deteriorating patients.
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Citation Excerpt :
This process added both individual learning and organisational development to increase both the individual’s and the organisation's effectiveness. The findings indicate that follow-up services may prevent adverse events, which agrees with results from Endacott et al. (2009). According to the participants, it was more common that the patient was returned to the ICU with a tracheostomy and respiratory problems before introducing PIG teams, which is in line with results from Tabanejad et al (2014).
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Research methodology/design: This study had a qualitative design. Data from 13 semi-structured interviews with Swedish critical care nurses and ward nurses were analysed using qualitative content analysis.
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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.10.011.

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Clinical paperImpact of an ICU Liaison Nurse Service on major adverse events in patients recently discharged from ICU☆

Abstract

Aim

Methods

Results

Conclusions

Introduction

Section snippets

Aims of the study

Methods

Sample

Intervention

Predictors and outcomes

Data collection

Data analysis

Results

Discussion

Conclusions

Conflict of interest

Acknowledgements

Aust Crit Care

Aust Crit Care

Intens Crit Care Nurs

Resuscitation

Aust Crit Care

Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital. Clinical guideline 50

A case–control study of patients readmitted to an intensive care unit

Crit Care Med

Patient care in the aftermath of discharge from an ICU

Am Fam Physician

Common concerns amid diverse systems: health care experiences in five countries

Health Affairs

Transitional care after ICU: current trends and future directions

Crit Care Nurs

Discharge from intensive care: a view from the ward

Intern Crit Care Nurs

The impact of a high dependency unit continuing education program on nursing practice and patient outcomes

Aust Crit Care

Delivery of surgical care in a district general hospital without high dependency unit facilities

Postgrad Med J

The nursing role in ICU outreach; an international exploratory study

Nurs Crit Care

Clinical paper
Impact of an ICU Liaison Nurse Service on major adverse events in patients recently discharged from ICU☆